Nebraska Oral Health State Plan. DRAFT September 7, 2011

Nebraska Oral Health State Plan DRAFT September 7, 2011

Letter to Stakeholders/ Public Acknowledgements List of Stakeholders and Contributors Table of Contents Process and Purpose of Plan A State Oral Health Plan is a strategic public health plan to systematically address the burden of oral disease and enhance the oral health of the citizens residing in the state. The plan establishes a vision for improving the oral health and well-being of the citizens of state and local communities, developing policies, and directing action. This plan is the result of the efforts of a dedicated group of public health professionals, dental health practitioners, primary care physicians, policy makers, educators and other individuals committed to improving oral health and oral health care in Nebraska. Building on the work of previous collaborative efforts (see page 13), the Office of Oral Health and Dentistry in the Nebraska Department of Health and Human Services invited more than 70 professionals to participate in a one-day Summit to identify critical needs in oral health and develop a plan for the future. Forty-five individuals from across the state attended the Summit held in Lincoln on May 24, 2011. Stakeholders included representatives of Local Public Health Departments, Federally-Qualified Health Centers, Colleges of Dentistry, Nebraska Public Schools, the Nebraska Dental Association, the Nebraska Dental Hygienists Association, Private Practice Organizations, the Nebraska Department of Education, the Nebraska Head Start-State Collaboration Office and the Nebraska Department of Health and Human Services. Summit participants articulated a vision for oral health in Nebraska and identified three priority focus areas for the next two to three years. These priority areas created a framework for the drafting of the State Plan. The Oral Health Advisory Panel (OHAP) reviewed the draft, which was then made available for public comment. After public input was incorporated, the OHAP reviewed and finalized the Nebraska Oral Health State Plan. The Office of Oral Health and Dentistry provided significant input and support throughout this process. The plan presented here is not a detailed action plan, but reflects the priorities of key stakeholders and the input of interested community members across the state. It is a working guide to be used by policymakers, health professionals, educators, community 2

programs and other stakeholders to identify and develop their role in helping Nebraska achieve the collective vision of optimal oral health care for all. As such, the plan is a living document, and stakeholders envision ongoing dialogue and the development of broad-based coalitions committed to refining and implementing the plan. All state and local organizations are encouraged to use this plan as a guide for oral health policy agendas and programming. The next step is to form collaborative working groups across stakeholder organizations to refine the strategies presented here, develop a timeline and identify specific action steps in each priority focus area. The Office of Oral Health and Dentistry will continue to guide the implementation of the plan, monitor progress, and solicit stakeholder input. Why Oral Health is Important Oral health is fundamental to overall health and wellbeing. Oral Health in America: A Report from the Surgeon General released in 2000 defines oral health as much more than healthy teeth. It calls for the development of a national oral health plan to address a disease that is almost entirely preventable. The report, a landmark in the oral health area, reveals profound disparities in oral health outcomes and access to care across the nation, presents the science linking oral health and overall well-being, and documents the value of prevention. The mouth and face can reflect signs and symptoms of health and disease that can indicate a host of conditions. Additionally, oral diseases and disorders can affect functions of daily life such as participation in work and school, and can influence quality of life issues such as communication, social interactions, and intimacy. Poor oral health has been linked to heart disease, diabetes, osteoporosis, and preterm delivery. Three years later in 2003, a public-private partnership led by the Office of the Surgeon General issued A National Call to Action to Promote Oral Health, which identifies specific action steps to reduce disparities and improve access to oral health care for all Americans. These action steps are: Change perceptions of oral health Overcome barriers by replicating effective programs and proven efforts Build the science base and accelerate science transfer surrounding oral health Increase oral health workforce diversity, capacity and flexibility Increase collaborations In 2011, the Institute of Medicine published Advancing Oral Health in America, which recommends strategic actions for Department of Health and Human Services (DHHS) 3

agencies to improve oral health and oral health care in America. These action steps include ten key principles: Establish high-level accountability Emphasize disease prevention and oral health promotion Improve oral health literacy and cultural competence Reduce oral health disparities Explore new models for payment and delivery of care Enhance the role of non-dental health care professionals Expand oral health research and improve data collection Promote collaboration among private and public stakeholders Measure progress toward short-term and long-term goals and objectives Advance the goals and objectives of Healthy People 2020. Healthy People 2020 is composed of 10-year goals and objectives for health promotion and disease prevention that integrate input from public health and prevention experts; federal, state and local government officials; over 2,000 organizations; and the public. There are seventeen Healthy People 2020 Oral Health Objectives, which address issues pertaining to: The oral health of children and adolescents The oral health of adults Access to preventive services Oral health interventions Monitoring & surveillance systems Public health infrastructure Dental care is the most common unmet treatment need in children. According to the Nebraska Open Mouth survey conducted in 2005, 59.3% of third graders had caries experience, which is significantly higher than the national Healthy People 2020 (HP2020) target of 49% for the 6 to 9 year old age group. More positive, only 17% of Nebraska third graders had untreated decay at the time of screening compared to the HP2020 objective of 25.9% for 6 to 9 year olds. Studies have shown that poor oral health can affect a child s ability to speak and eat, distract from learning and playing, and increase absence from school. In severe cases, decay can impact normal height and weight gain in toddlers and may compromise overall health. 4

Oral disease is progressive and cumulative and treatment becomes more complex with age. Oral disease in adults can affect economic productivity and compromise the ability to work at home or on the job. While Nebraska exceeds the HP2020 objectives for adults in two areas, the most recent results from the Behavioral Risk Factors Surveillance System show that dental visits have declined. Thirty two percent of adults did not visit a dentist in 2010 compared to 25% in 2004. More positive is that 74% of adults age 35-44 have never had a permanent tooth extracted because of dental decay or periodontal disease, up significantly from 64% in 1999. Prevention measures such as water fluoridation, sealants, topical fluorides, and screening beginning at age one can reduce decay significantly, but not all Nebraskans have equal access to these programs. Minorities According to the Nebraska Open Mouth Survey, African American and Hispanic children and children from low-income schools have significantly higher treatment needs (including rampant caries) compared to non-minorities and children from higher income schools. Given the rapid growth of the Hispanic population in Nebraska, this disparity may signal a growing need. On the positive side, 53% of Medicaid-enrolled children are receiving dental care compared to 38.1% nationally. Dental screening of nearly all Head Start children identified 17% needing treatment and 92% of those received treatment. Immigrants/Refugees Nebraska s population continues to become increasingly diverse. According to 2010 data from the US Census Bureau, Nebraska s Hispanic, Black, Asian, and American Indian populations represent 9.2%, 4.5%, 1.8%, and 1.0% of the state s total population, respectively. In addition, 9.2% of Nebraskans report speaking a language other than English at home. As Nebraska becomes a home for more racial ethnic minority, immigrant and refugee families, the provision of culturally and linguistically appropriate care is becoming a matter of increasingly critical importance. 5

Pregnant Women and Mothers Improving the oral health of pregnant women prevents complications of dental diseases during pregnancy, has the potential to decrease early childhood caries and may reduce preterm and low birth weight deliveries. In 2009, 31% of expectant mothers with children in the Nebraska Head Start and Early Head Start program received dental exams or treatment. Special Health Care Needs Nebraskans with disabilities have unique oral health care needs. When you ve seen one child with special health care needs, you ve seen only ONE child with special health care needs. PTI Nebraska and the NE Planning Council for Developmental Disabilities conducted focus groups in 2008 with parents of disabled children. Participants identified specific oral health concerns within this population including the lack of providers who are trained in working with children with special needs, physical accessibility, and understanding the individual needs of children and families. Older Adults Seniors also have significant oral health needs, including an increased likelihood of severe periodontal disease. Barriers to care include a lack of dental insurance, the exclusion of routine dental care benefits under Medicare, and transportation issues. Low-income seniors in Nebraska who qualify for Medicaid have coverage for routine and other care. Outcomes for all Nebraska seniors are increasingly more positive; a key indicator, the percentage of older Nebraskans that have had all their permanent teeth extracted, has declined significantly from 23% in 2004 to 15% in 2010. (10) Rural Areas Many Nebraskans living in rural areas face significant shortages in dental services and personnel. The Nebraska Governor s Rural Health Advisory Commission has designated 53 of the state s 93 counties as Dental Health Professional Shortage Areas. As of April 2008, 20 counties reported having no dentist, and an additional 32 counties have only one or two dentists. 2010 data from the US Census Bureau shows that Nebraska has an average of 23.8 persons per square mile, compared to the national average of 87.3 persons per square mile. 6

Vision Nebraskans, including health care professionals, parents, educators, funders, lawmakers and policy makers, recognize the importance of oral health to overall health across the lifespan by adopting good oral health behaviors and by supporting policies and programs to provide access to optimal oral health care and dental homes for all. The Vision and the work outlined in this Plan will be guided by the following principles and values: A strong commitment to the vision by all stakeholders A collaborative approach in planning and implementation Oral health care should be accessible and easy for consumers to navigate Priority Focus Areas The following three Focus Areas are priorities for policy, funding, and programming efforts in the next two to three years. Policy and Environmental Change This area impacts all five actions in the National Call to Action and the Healthy People 2020 objectives. Priority Focus Objective 1: Create an environment where public policy supports access to optimal oral health care for all Nebraskans. Rationale: Nebraska does not have an oral health data and surveillance system, which puts the state at a disadvantage compared to other states when competing for funding. The lack of data makes it difficult to demonstrate the effectiveness of programs, which in turn impacts resource allocation. Oral health stakeholders and stakeholder organizations can be more effective in their efforts to influence public policies when they speak with a common voice. 7

State Medicaid policy sets reimbursement rates for providers of oral health services to high-risk populations. The impact of reimbursement rates on access to care is unclear. Strategies: 1a. Develop an oral health surveillance system for tracking oral health outcomes, including outcomes from prevention programs, to be used to support policy initiatives, funding requests, and planning decisions. 1b. Develop and implement a framework for bringing stakeholder organizations together to identify public policy issues that affect oral health and to advocate for change with a common voice. 1c. Establish a legislative issues forum on oral health for Public Health Directors. 1d. Examine the effects of current public reimbursement policy, programs and priorities on access to oral health care. Priority Focus Objective 2: Establish as a common practice the recommendation that all children have their first dental screening by age one. Rationale: The American Academy of Pediatric Dentistry, the American Dental Association, the American Academy of Pediatrics, and the Bright Futures Consortium have issued and endorsed policy statements on screening children, particularly those in high risk groups, by age one. The recommendation is based on the finding that the transmission of oral caries bacteria usually occurs after the eruption of the first teeth. A dental home is also recommended for all children because the environment promotes a more cost effective and higher quality alternative to emergency/urgent care scenarios. Strategy: 2a. Facilitate dialogue and collaboration between oral health professionals, the medical community, and educators about the need for dental screenings by age one, and to develop education and training programs to implement the standard. 8

Workforce Development The diversification and expansion of the Oral Health Workforce is an established priority reflected in the Surgeon General s National Call to Action to Promote Oral Health (2003) and in the Institute of Medicine s Advancing Oral Health in America (2011). As the oral health care needs of Nebraska s population evolve, so too must the roles and responsibilities of Nebraska s oral health care workforce. Priority Focus Objective 3: Expand oral health care access, particularly to under-served populations, through workforce models that promote diversity and use resources effectively and efficiently. Rationale: The Nebraska Dental Workforce Committee reports that Nebraska s two most populous counties (Douglas and Lancaster, which contain Omaha and Lincoln) account for 44% of the state s population and 56% of the dental workforce. The Nebraska Governor s Rural Health Advisory Commission has designated 53 of Nebraska s 93 counties as State Dental Health Professional Shortage Areas. (See the Appendix for service and shortage area maps) As of April 2008, 20 counties were reported to have no dentist, and an additional 32 counties had only one or two dentists. The ratio of population-to-dentist was estimated as 1,787 to one for all of Nebraska. The contrast between urban and rural areas of the state is striking. In urban areas the population-to-dentist ratio is 1,517 to one, while the ratio in the remaining 90 rural counties is 9,960 to one. The uneven distribution of dentists is complicated by the fact that many are nearing retirement age. A 2007 projection by the University of Nebraska Medical Center Health Professions Tracking Center revealed that 24% of Nebraska s dentists planned to retire by 2017. Strategies: 3a. Explore alternative workforce models, including the effects of scope of practice on access to care for underserved populations. 3b. Enhance the comprehensive services available at public dental clinics across the state by recruiting and using community health ambassadors. 9

3c. Provide culturally and linguistically appropriate services to promote the accurate communication of oral health information and the effective adoption of oral health practices. 3d. Increase tuition reimbursement programs to encourage more dentists in rural and underserved areas. Social Marketing Social marketing is the application of marketing principles and concepts intended to achieve specific behavioral goals. In the context of oral health, social marketing efforts directly relate to several action steps identified in the National Call to Action and Advancing Oral Health in America, including changing perceptions of oral health, emphasizing disease prevention and oral health promotion, and improving oral health literacy and cultural competence. Rationale: As stated in the Call to Action, For too long, the perception that oral health is in some way less important than and separate from general health has been deeply ingrained in American consciousness. Changing perceptions of the importance of oral health to overall well being and educating Nebraskans about the connection between oral health and specific diseases such as obesity and diabetes is critical to increasing the number of Nebraskans receiving preventative care. Fluoridation of public water supplies is the single most effective prevention strategy because it reaches everyone in a community, including those who cannot otherwise afford regular dental care. In Nebraska, 69.9% of residents have a fluoridated water supply, slightly less than the 72.4% nationwide. Strategies: Priority Focus Objective 4: Educate Nebraskans about the importance of good oral health to overall health and build a sense of personal responsibility for regular oral health care and screening. 4a. Secure funding and implement a professionally developed, statewide social marketing campaign targeting parents, professionals, policy 10

makers and the public with consistent and culturally appropriate messages about oral health and overall wellbeing and prevention. 4b. Educate parents, particularly those in populations that have high risk for dental caries and low access to care, about the importance of regular dental screening by age one. 4c. Educate decision makers and residents in local communities choosing not to add fluoride to their public water supply, about the preventive value of fluoridation and address misconceptions. Focus Areas for the Future As oral health in Nebraska benefits from increased collaboration, unification of efforts, and a common vision for the state, the scope, content and operation of oral health activities and programs will become more effective, efficient, and comprehensive. The following areas were identified as critical in improving access to oral health care in Nebraska, and were designated as long-term priority focus areas. Adequate and sustainable funding for current and future programs to increase access to care and regular screening. More place-based activities, particularly school based sealant and tooth brushing programs. 11

Appendices A. Current Programs and Collaborations Following is a summary of state-supported programs and planning efforts for oral health. Nebraska Department of Health and Human Services, Division of Public Health, Health Promotion Unit, Office of Oral Health and Dentistry Maternal and Child Health Block Grant used for support of the Director, ongoing Health Access for Young Children grant to extend oral access program to 15 Federally Qualified Health Centers (FQHC) and public health departments in Nebraska, began 2011 and extends through 2012 Preventive Health Services Block Grant supports the Two Rivers school-based brushing program and SONRISA, a dental access program for low-income children, through the South Heartland District Health Department in collaboration with the community college dental hygienist program, began in May 2009 Collaboration with Boys Town Pediatrics to disseminate a fluoride toolkit to all primary care physicians across the state. Nebraska Department of Health and Human Services, Division of Public Health, Lifespan Health Services Unit Strategic Access Workshop (SAW) held in 2008. Funded by HRSA and the Maternal Child Health Block Grant Participants were stakeholders in maternal and child oral health. The maternal and child population includes infants, children, and adolescents, including those with special needs, and pregnant women and mothers Goals: - Build an effective state oral health coalition - Move forward with a focus on prevention - Develop policy recommendations - Communicate the message that dental care and dental health are critical issues - Strengthen cultural competence in oral health care, including care for children with special needs Together for Kids and Families (TFKF): Nebraska Early Childhood Comprehensive Systems Grant Project - Joint funding with Head Start State Collaborative Office to promote oral health systems development - TFKF strategic plan implementation began in 2006 - Home work group continued to actively address oral health issues - UNMC Dental College active participation in Medical Home Work Group 12

- Access Work Group initial focus on language and transportation issues shifted almost exclusively to oral health access - Provided arena for dialog across projects: Oral Health SAW, PTI s Families and Professionals Oral Health forum, and Head Start State Collaboration Office and NE Head Start Association efforts - Exploration of role of Pediatrician in providing oral health early screening for infants in office - Partnered around access to oral health issues with community-level Learning Collaborative via Nebraska s CB-CAP agency; NE Children and Families Foundation Family-to-Family Health at PTI Nebraska and NE Planning Council for Developmental Disabilities Oral Health Forum Concerns and Recommendations Action Plan Collaborate with dental colleges in Nebraska Create pre-visit form for families Create interview questions for families Availability to respond to questions about oral health New Activities Funded by ASTDD Additional funding in 2009 NE Medicaid: Oral Health codes available to PCP for fluoride varnish Nebraska Head Start Oral Health has been a Head Start federal priority for several years Nebraska s Head Start-State Collaboration Office (HSSCO) goals have included a focus on oral health since 2001 HSSCO supports and addresses systems issues of access, preventive services, safety net resources for grantees, especially in rural Nebraska. In partnership with key stakeholders and other policy makers, HSSCO goal is to assist in the development and inauguration of a statewide oral health coalition to address issues: Access to quality, affordable oral health care Preventive care in a dental home, Education for practitioners, providers, parents. Program examples: Hastings Head Start; National Health Literacy Training; Take Home Toothbrush funded by HRSA grant, funded through August 2012 Collaborating agencies/programs: Nebraska Head Start Association; Together for Kids & Families, DHHS Lifespan Health; University of Nebraska Medical Center College of Dentistry; Region VII ACF-Head Start and Technical Assistance, Nebraska Office of Oral Health & Dentistry. Head Start Dental Home Initiative: Head Start has partnered with the Nebraska Dental Association and the American Academy of Pediatric Dentistry to develop a network of pediatric dentists and general dentists to provide quality dental homes for Head Start (HS) and Early Head Start (EHS) children; to train teams of 13

dentists and HS personnel in optimal oral health care practices; and to assist HS programs in obtaining comprehensive services to meet the full range of HS children s oral health needs. (Per US DHHS Office of Head Start Program Information Report 2009-2010) 88.3% of Head Start children received preventative dental care Out of 90.4% of Head Start children completing an oral health exam, 16.6% needed dental treatment and 91.6% of those received treatment; 88.8% of EHS/Migrant received preventative dental care services 30.6% of pregnant women received dental exams or treatment 96.6% of Head Start children had dental home Three American Indian Head Start programs are located at Santee Sioux [n=35]; Winnebago [n=90]; and Macy Um n hon Tribe [n=101]. In 2009-10 program year (most recent federal data), the total federally funded enrollment was 5,452. Another 123 children were funded by a non-federal entity for a total of 5,575 children enrolled. The cumulative enrollment for Head Start preschool children including migrant children was 4,892. The cumulative enrollment for Early Head Start children was 1,457. 14

UNMC College of Dentistry Outreach Programs UNMC COLLEGE OF DENTISTRY OUTREACH PROGRAMS PROGRAM # VOLUNTEERS # SERVED Clinic With a Heart, Lincoln 80 160 annually, adults Grand Island Extraction Clinic 12 60 annually, adults SHARING Clinic (quarterly) 150 each clinic 250 annually, adults Children s Dental Day (comprehensive care ex orthodontics) Lincoln 250 200 annually Panhandle 50 200 annually Sonrisa (Hastings) 30 100 annually NE Mission of Mercy 50 1200 Sealing Smiles, school based for 2 nd, 3 rd, and 6 th grade children, includes exam, prophylaxis, fluoride varnish, sealants, referral as needed Omaha, 8 schools 22 1200 annually Lincoln, 8 schools 22 1200 annually Panhandle, 4 schools 10 400 annually Back to School Exams with People s Health Center, Lincoln 20 40-60 annually In school POH instructions to all 2 nd grade children in Lincoln, done by D-2 class upon invitation from schools 45 2500 annually, children Oral cancer screenings upon request and as needed 45 50 annually, adults Extramural rotations by D-4 students for 4 weeks- 180 total weeks annually 45 4-5000 annually Additional outreach by Pediatric Dentistry residency program in Omaha UNMC College of Dentistry, received May 25, 2011. 15

Creighton University School of Dentistry Outreach Programs in Nebraska CREIGHTON UNIVERSITY SCHOOL OF DENTISTRY OUTREACH PROGRAMS IN NEBRASKA Programs from May 1, 2010 April 30, 2011 PROGRAM # VOLUNTEERS # SERVED EDUCATION PROGRAMS: Community or school-based health fairs 180 7,359 annually, adults and children Community or school-based oral health education 240 2,009 annually, children Community-based oral health education 60 314 annually, adults SCREENING PROGRAMS: Oral health screening 210 1,487 annually, adults and children PREVENTIVE DENTISTRY SERVICES: School-based fluoride varnish programs 18 271 annually, children GENERAL DENTISTRY SERVICES: Extramural rotations by senior dental students Thursday Night Clinic at Creighton Dental School Give Kids A Smile Creighton Dental School One World Community Health Centers 71 2,313 annually, adults and children 160 860 annually, adults 45 7 68 children 21 children NE Mission of Mercy 12 1,378 adults and children TOTAL 1,003 16,080 Creighton University School of Dentistry, received September 8, 2011. 16

B. Prevalence, Risk Factors and Workforce Selected Charts from the Open Mouth Survey of Nebraska Third Graders 2005, Nebraska Health and Human Services System. 17

Nebraska Health and Human Services System. Open Mouth Survey of Third Graders Nebraska 2005, Lincoln, NE: Nebraska Health and Human Services System, 2005. 18

Nebraska Department of Health and Human Services. BFRSS Summary Fact Sheet, Volume 2, Issue 2, May 2011. 22

Comparison to Healthy People 2010 and 2020 objectives Objectives for Children Untreated Cavities: Nebraska exceeds the National Healthy People 2020: Oral Health Objectives in the proportion of 6 to 9 year olds with untreated caries in permanent or primary teeth: National HP 2020 Objective is 25.9%; NE 2005 is 17%. Dental Sealants: Nebraska also exceeds the 2020 Objective for the proportion of 6 to 9 year olds with dental sealants: HP 2020 Objective is 28.1%; NE 2005 is 45.3%. (Note: Nebraska percentage is based on 8 to 9 year olds.) Cavity Experience: There is room for improvement in the proportion of 6 to 9 year old children who have experienced dental caries: HP 2020 Objective is 49%; NE 2005 is 59.3%. Objectives for Adults Nebraska exceeds the following National Healthy People 2020 Objectives in two areas: Percent of adults aged 45 to 64 who have ever had a permanent tooth extracted because of dental caries or periodontal disease: National: 68.8 Nebraska: Aged 45 to 54 40.7 (2010 NE BFRSS) Aged 55 to 64 55.1 (2010 NE BFRSS) Percent of adults age 65 to 74 who have had all of their permanent teeth extracted: National: 21.6 Nebraska: 13.7 (2010 NE BFRSS) Nebraska falls below the national objective for the proportion of the population with access to fluoridated community water supply: National: 79.6 Nebraska: 69.9 (2008) Workforce Shortage Areas The following maps illustrate oral health workforce characteristics and shortage areas in Nebraska. 23